The Journal of thoracic and cardiovascular surgery · 2025
Challenging the transcatheter-first paradigm: Redo surgical aortic valve replacement after previous transcatheter or surgical aortic valve replacement.
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Fukuhara Shinichi, Ling Carol, Patel Himanshu J, Hamilton Barbara C S, Hawkins Robert B, Ailawadi Gorav, Yang Bo
Аннотация
OBJECTIVE: Aortic valve reoperations after transcatheter aortic valve replacement (TAVR) are increasing. However, concerns persist regarding poor clinical outcomes, whereas high cohort heterogeneity has historically precluded meaningful comparative analyses.
METHODS: We identified 1024 consecutive patients who underwent surgical aortic valve replacement (SAVR) after either TAVR (TAVR-SAVR; n = 127) or SAVR (SAVR-SAVR; n = 897) between 2011 and 2024. Among these, patients undergoing isolated SAVR ± coronary artery bypass grafting were included: 57 in the TAVR-SAVR group and 447 in the SAVR-SAVR group.
RESULTS: The proportion of TAVR-SAVR among all aortic valve reoperations increased from 0% in 2011-2012 to 31.3% in 2024. Patients in the TAVR-SAVR group were older, exhibited greater comorbidity and heart failure burden, and had greater Society of Thoracic Surgeons Predicted Risk of Mortality. Despite 61.2% of TAVR-SAVR patients lacking previous sternotomy with shorter cardiopulmonary bypass and aortic crossclamp times, they demonstrated significantly greater operative mortality (12.3% vs 1.1%, P < .001). In contrast, the SAVR-SAVR cohort exhibited a remarkably low observed-to-expected mortality ratio of 0.33 (95% confidence interval, 0.11-0.76). After 1:2 propensity score matching (50 TAVR-SAVR vs 93 SAVR-SAVR patients), the TAVR-SAVR group continued to show greater operative mortality (12.0% vs 1.1%, P = .008) and greater composite complication rates.
CONCLUSIONS: TAVR-SAVR cases are increasing and may surpass SAVR-SAVR cases by 2029. Despite matching, patients undergoing SAVR ± coronary artery bypass grafting showed worse outcomes in TAVR-SAVR, whereas a SAVR-SAVR strategy was extremely safe. Reconsideration of the TAVR-first strategy is warranted for patients expected to outlive the durability of TAVR prostheses.
METHODS: We identified 1024 consecutive patients who underwent surgical aortic valve replacement (SAVR) after either TAVR (TAVR-SAVR; n = 127) or SAVR (SAVR-SAVR; n = 897) between 2011 and 2024. Among these, patients undergoing isolated SAVR ± coronary artery bypass grafting were included: 57 in the TAVR-SAVR group and 447 in the SAVR-SAVR group.
RESULTS: The proportion of TAVR-SAVR among all aortic valve reoperations increased from 0% in 2011-2012 to 31.3% in 2024. Patients in the TAVR-SAVR group were older, exhibited greater comorbidity and heart failure burden, and had greater Society of Thoracic Surgeons Predicted Risk of Mortality. Despite 61.2% of TAVR-SAVR patients lacking previous sternotomy with shorter cardiopulmonary bypass and aortic crossclamp times, they demonstrated significantly greater operative mortality (12.3% vs 1.1%, P < .001). In contrast, the SAVR-SAVR cohort exhibited a remarkably low observed-to-expected mortality ratio of 0.33 (95% confidence interval, 0.11-0.76). After 1:2 propensity score matching (50 TAVR-SAVR vs 93 SAVR-SAVR patients), the TAVR-SAVR group continued to show greater operative mortality (12.0% vs 1.1%, P = .008) and greater composite complication rates.
CONCLUSIONS: TAVR-SAVR cases are increasing and may surpass SAVR-SAVR cases by 2029. Despite matching, patients undergoing SAVR ± coronary artery bypass grafting showed worse outcomes in TAVR-SAVR, whereas a SAVR-SAVR strategy was extremely safe. Reconsideration of the TAVR-first strategy is warranted for patients expected to outlive the durability of TAVR prostheses.